Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, March 17, 2008

Monsieur Laplace

I like that song "It was a Crazy Game of Poker" by O.A.R. Over the weekend I had a crazy game of "Take the Old Guy to the OR a Couple of Times after he Intitially Presented with a Myocardial Infarction" Fun times!

Nice 88 year old guy presented to the ER with chest pain and was ultimately diagnosed with a non-ST segment elevation myocardial infarction (NSTEMI). They had him on heparin and aspirin and the cardiologist had determined that he wasn't a candidate for intervention. So he was hanging out on the floor being anti-coagulated, waiting for a bed at the local rehab facility. And then he developed acute, severe left groin pain. PCP gets the CT scan and I get called friday evening about an incarcerated iguinal hernia. My wife loves those calls. It means dinner is off and she gets to eat leftover scraps from the fridge. When I saw him, his belly was distended and tympanitic, but non-tender. He did have a hard mass in the groin that wasn't going anywhere without a knife. I looked at the CT scan (no comments from the peanut gallery on why it was ordered) and it showed what appeared to be sigmoid colon incarcerated in a left sided inguinal hernia. Proximally the colon was understandably dilated, transverse and cecum looked to be about 8cm. I approached the hernia via a standard groin incision. The bowel-containing sac was separated from the cord structures and then I carefully opened the thick walled sac to inspect the contents. Sure enough, it was sigmoid colon, pink and healthy. I pushed everything back through the internal ring and performed a standard plug and patch repair with mesh. We did the case under spinal and the old guy tolerated it quite well. The next day he looked pretty darn good. His belly was softer and I thought a moment about removing his NG but in the end decided not to. I started thinking maybe I was going to get away with a nice save on the guy...

And then Sunday I made rounds and he seemed disoriented and anxious. He kept clutching at his belly and it was firmer and certainly more tender. I sent for a stat CT and finished seeing the last five patients on my list. Half an hour later the scan is done and he's got free air. Lots of it. I rush back and he's starting to drop his pressures and look a little mottled. For the love of God. I'm not thinking he can handle anymore surgery but the family wants the full court press so back to the OR we go. Thankfully the sigmoid looks fine. The hernia site doesn't seem to be the problem. But the cecum is bluish-black and paper thin and there's a dime sized hole in the anterior wall. Ileocecectomy, end ileostomy, mucus fistula in about 20 minutes. Stool evacuated and peritoneum lavaged with saline. Back to the ICU on multiple pressors and a few prayers.... He's actually doing well today. Fingers still crossed though.

So what happened? There's an entity in physics known as the Law of Laplace which describes the relationship between pressure, tension and a hollow tube's diameter. Essentially, bigger tubes have a larger amount of wall tension at a given pressure compared to smaller tubes. The cecum is the widest part of the large bowel. Therefore, any obstructive situation that raises the pressure of the colon will generally put the cecum at risk of rupture prior to anywhere else. But I relieved the obstruction with the hernia repair. What happened? Well, my theory is that he simply did not spontaneously decompress the accumulated air as expected when the mechanical obstruction had been resolved. He developed a peristent ileus and time and pressure did the rest. What could I have done differently? Maybe repaired the hernia via a laparotomy. That way I could have examined the entire contents of the abdominal cavity. But I'm not convinced I would have seen evidence of ischemia at that time. His WBC was normal and there no real abdominal tenderness, other than directly over the incarcerated hernia. More likely, I would have seen a dilated cecum, maybe with non-specific inflammatory changes. Then what? Cecostomy tube for decompression, with all the attendant morbidity of such a procedure? Tough call. At the very least I was able to prove that recent acute MI is not a contraindication to performing multiple operations on frail 88 year old men. Just kidding. Don't do what I do. Go into dermatology. Anyway, time for a Guinness. Happy St. Pats.

Who knows? There's hardly a case about which one can't second guess. I think distended bowel is among the hardest of judgments, in terms of when to intervene, absent obvious obstruction or other signs. I'm quite sure I'd have done the same. Had you opened for a look around initially, and had he not done well, you'd have wished you'd done the groin approach only. With great trepidation, on a couple of occasions when I thought it the least of many evils, I've had GI do a very gentle and minimally air-infusing decompressive colonoscopy. (Or so I recall. Maybe I only wondered if it would work...)

Sid, the other thing I could have done is stuck a laparoscope through the opened hernia sac and looked around. But again, what would I have done if the cecum merely looked "dilated"? I hate cecostomy tubes. I like the idea of decompressive colonoscopy, but it seems the GI guys (who will otherwise scope anything/anytime) absolutely hate doing it for that indication.

I like that scope through the hernia sac idea. Not sure it would have changed management unless you visualized ugly looking cecum. Regardless, is that described anywhere? Have you seen that done or have you done it before? I've never seen anyone do that. Makes sense though

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